Outpatient Use of Oral Propranolol and Topical Timolol for Infantile Hemangiomas: Survey Results and Comparison with Propranolol Consensus Statement Guidelines

Abstract

Oral and topical β-blockers are used to treat infantile hemangiomas (IHs). Although a recent consensus report provided guidelines for the treatment of IH with propranolol, there are no standard guidelines for the use of topical timolol. The objectives of this study were to determine the current use of oral propranolol and topical timolol by pediatric dermatologists in an outpatient setting and to compare current propranolol use with published propranolol consensus guidelines. An electronic survey was sent to pediatric dermatologists in May and June 2013. One hundred forty-nine pediatric dermatologists responded to the survey, a 79% response rate. Of the respondents, 96% prescribed oral propranolol, but 75% did not follow consensus guidelines exactly; recommended history, physical examination, initial dose, and frequency varied. The dose of propranolol was usually titrated up to goal dose as recommended (89%). Fifty-six percent monitored vital signs in patients after the initial dose and 49% continued to monitor vital signs in their clinic after each dose escalation, which did not meet consensus guideline recommendations. Ninety-one percent reported using topical timolol for the treatment of IH and 66% responded they had used topical timolol in conjunction with oral propranolol to treat IH. The most common indication was superficial hemangiomas (97%). Most practitioners (74%) did not routinely monitor heart rate or blood pressure in infants treated with topical timolol. This study highlights the variability in prescribing and monitoring practices of physicians using propranolol for the treatment of IHs and demonstrates that topical timolol is commonly used alone and in conjunction with oral propranolol to treat IHs.

Review of topical beta blockers as treatment for infantile hemangiomas

“…On starting treatment, children less than or equal to 8 weeks gestational age should be admitted for monitoring, while all other children should be monitored with heart rates and blood pressures obtained at baseline and 1 and 2 hours after commencing treatment or after a dose increase. Kumar's survey of pediatric dermatologists found that, despite the consensus recommendations, 75% of clinicians used variations in dose, monitoring, history, and examination (21) .…”

“…Bonifazi first published the use of 1% propranolol ointment for six superficial hemangiomas in 2008, while Pope and Chakkittakaniyil began to use topical timolol maleate 0.5% gel, in 2009 (3,37) . A recent survey of pediatric dermatologists showed that 91% of those surveyed use topical timolol, 66% in conjunction with oral propranolol (21) . We review the use of topical beta blockers in the treatment of infantile hemangiomas.…”

Topical Treatment of Infantile Haemangiomas: A Comparative Study on the Selection of a Semi-Solid Vehicle

“…Although the published data seem to demonstrate the clinical efficacy of topical PR, therapeutic protocols and guidelines have not yet been established. Indeed, the results of clinical studies published in the literature are ambiguous due to the empirical choice of semi-solid bases other than the differences in clinical protocols (e.g., study design, selection of patients, and end points) [12]. …”

Safety profile during initiation of propranolol for treatment of infantile haemangiomas in an ambulatory day‐care hospitalization setting

“…The frequency of dosing varied, with 31% of respondents dosing twice daily, 55% three times daily and 16% at other intervals. Only about half the responders monitored haemodynamic parameters 1–2 h after the initial dose (56%) and after each dose escalation (49%) …”